Common Reasons for Denial

• Medicare does not pay for this item or supply when provided by a non-contract supplier
• Only contract suppliers may provide brace with the exception of Non-Contract Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists with special modifiers and non-contract suppliers providing items to a traveling beneficiary

Next Step

• Non-Contracted Suppliers submitting claims for beneficiaries that reside in a CBA and do not meet the definition of a traveling beneficiary, will need to obtain a properly executed ABN, prior to providing item, for off-the-shelf (OTS) back and knee braces, with the exception of Non-Contract Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists. Suppliers that provide off-the-shelf (OTS) back and knees braces without a properly executed ABN cannot collect payment from the beneficiary

How to Avoid Future Denials

• Check eligibility on the Noridian Medicare Portal to verify the beneficiary's permanent address on file with the Social Security Administration prior to providing service.
• Utilize the Round 2021 CBA Zip Code Lookup Tool to verify if beneficiary's permanent address resides in a CBA
  • Only contract suppliers may provide brace with the exception of Non-Contract Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists and non-contract suppliers providing items to a traveling beneficiary
• Utilize the Competitive Bid HCPCS Lookup Tool to verify if item is a competitive bid item and if item requires prior authorization, face-to-face and written order prior to delivery
• Please refer to the Competitive Bidding page on the Noridian Medicare website for more information.